Wednesday, March 31, 2010

Front load some of the benefits, back load the costs and the compulsions, put them all together in a behemoth sized bill of mind boggling complexity and ambiguity and voila you have health care reform reform passed with 2 or 3 votes to spare. Here is cogent discussion of why the bill is so long and so complex when a few pages could have described a plan to give subsidies to those too poor to purchase health insurance. Could it be more than just a health care bill?

Apparently Senator Baucus thinks the health care bill may serve at least other or perhaps more important purpose.See here for that story. Here is what he is quoted as saying:"Too often, much of late, the last couple three years, the mal-distribution of income in American is gone up way too much, the wealthy are getting way, way too wealthy and the middle income class is left behind," "Wages have not kept up with increased income of the highest income in America. This legislation will have the effect of addressing that mal-distribution of income in America."

Vice-President, Joe Biden, however says no, It is just being fair.See here

To the extent that Baucus has corrected characterized the legislation there are those who would believe that social justice has been well served as it is always said to be when wealth is redistributed.To those folks I submit the following commentary by the economist D.W.MacKensie

While we cannot be sure about the details of future changes in government regulations or programs, economic theory indicates that these costs rise over time. Ideally, legislators pursue what some people term ‘social justice’ through redistribution. The term social justice lacks any objective meaning. People have different opinions as to what constitutes a fair redistribution of wealth, and there is no objective criterion for determining whose version of social justice is correct. No one can comprehend all the factors that would have to enter into an actual estimate of ‘socially just’ income distribution. Claims of social justice are at best based on narrow and incomplete value judgments, and at worst completely arbitrary opinions. Since social justice has no meaning, the pursuit of this goal inevitably degenerates into power struggles among interest groups.

"Power struggles by special interests groups" is a concept not typically taught in high school civics class.

Sunday, March 28, 2010

Henry Waxman appears angry (see here ) that CEOs of corporations dare tell the public that they will loose money from Obamacare and will haul them before tv cameras in a hearing room and ...

I suppose he might challenge them saying that how dare they know more about their own financial bottom line that the policy wonks who allege great savings for all.Surely folks who run businesses do not know more about their business than a government staffer who knows little or none of the particulars of the costs and other elements of a given business enterprise. It just gets better and better.

Earth hour,"celebrated" each March 27 (see here for details) has come and gone for this year. Celebrants will not have wait another year for this joyous occasion.At lest one country observes this ritual every night.See here.

Wednesday, March 17, 2010

A recent poll of U.S. physicians was published in the NEJM,(see here).About 46% of primary care physicians indicated they would leave practice or at least seriously consider leaving practice if some version the Senate health care bill becomes law.

The law will increase the number of patients covered under Medicaid and if big cuts occur in the Medicare Advantage there will be an increase in the number of folks moving to regular Medicare.We will have a situation in which there will be more patients trying to obtain care from fewer physicians. Those physicians remaining in the Medicare/Medicare treating group will be faced with increasing regulations and controls and ultimately further decreases in payments as the approximately $500 million in projected "savings" in Medicare payments play out. This in turn is likely to spral down with more physicians "going Galt".

Waiting lists , shortages and decreased quality likely will result. In Massachusetts with its version of what is to come nationally there are much longer wait times for physician visits even in spite of the very high per capita number of docs in that state.

Having health insurance is not equivalent to receiving health care. Who typically gets the goods or services that are in short supply due to government controls, the well to-do and well connected or the poor and less well connected? Either through accessing retainer practices ( it will take a while to outlaw them) or other means of getting to the front of the line or getting care out of the country the richer and more connected will , as always do much better. Those who will not are some the same folks who are the alleged beneficiaries of this deconstruction/reconstruction of health care.

Sunday, March 07, 2010

Dr. David Rind in his blog "Evidence in Medicine" tackles an issue that has bothered me for some time.See here.That issue is, in the form of a question, is " are meta-analyses (MAs) really helpful" or not. I have questioned whether MAs should sit as high as they do on the generally accepted hierarchy of evidence based medicine. See here for my overly lengthy comments on why MA should not share the pinnacle position on the evidence based medicine hierarchy with randomized clinical trials and why the hierarchy scheme itself is flawed.

In his commentary he lists some of the reasons why they may be neither helpful nor productive of new insights. He is not saying MAs are never helpful ( and neither am I) and in fact takes the position that a recent MA regarding statins and diabetes does provide useful information .

Why may MAs sometimes not be very useful. Here are some of the reasons Rind lists and some others:

From Dr. Rind's commentary

1) Frequently... meta-analyses are either driven by the single large RCT that everyone would have cited anyway or, worse, a number of small, poorly-performed RCTs are combined with a moderate-sized, well-performed RCT and alter the results away from what was likely the best estimate of reality: the results of the well-performed RCT.

Sculpturing the numbers from several small, poorly done RCTs is no guarantee of discovering the clinical truth and may well give credence to some bad ideas.

3.MAs authored by folks with little or not subject matter expertise cannot or do not put the issues in a context that would have born of actual experience.

4.MAs that lump apples and peaches. I am reminded of one MA that looked at all thrombolytics. You don't write an order for "a thrombolytic" you write for a specific one.

5.Remembering that a meta-analysis is really an observational study in which the observed entities are trials,there is a real risk that the investigators might pre-screen the trails and in a post hoc fashion devise inclusion or exclusion criteria that would stack the deck to favor a conclusion that they already "knew was right".